What an incredible year 2014 was for our Cornish Living Well Pioneers – people who really pushed the boundaries of what can be achieved when you work in new ways. We call them our ‘boat rockers’ as they are not worried about making waves.

Our team comprises people who are desperate to exist beyond the confines of traditional ways of working. It’s a rapidly growing fleet of people from the voluntary, public and private sector: doctors, nurses, police officers and other local people who give up their free time to help others and make our community better. They’re not interested in which organisation is supposed to support Mary at number 20 with her mobility issue, they just want to help her get back on her feet and out of her home for the first time in three months.

We launched Living Well in 2012, bringing together two local authorities, the NHS, Age UK Cornwall and the Isles of Scilly, community services and Volunteer Cornwall to provide bespoke, wrap-around care that meets people’s individual needs and ambitions.

During the past two years we’ve supported nearly 1,000 people who have one or more long-term condition and are at risk of being admitted to hospital. Our approach is to help build people’s self-confidence and self-reliance by providing practical support, care co-ordination and connecting them with people in their community who can support them.

This begins with a conversation, where the person tells an Age UK co-ordinator their goal. This could be anything from supporting someone to build up their stamina to walk their dog on the beach, to connecting them with new friends in their community. You may wonder why the NHS and councils are helping people to make friends, but we know there may be up to 20,000 people in Cornwall who are lonely and isolated and the only ‘human’ contact they have is their TV, pet, doctor, nurse, or carer.

In Newquay we discovered that around half of the 100 people we saw hadn’t left their home for more than a year – some for three or more years – and it’s these people who are at risk of becoming withdrawn and depressed; are at increased risk of mortality; and are more likely to visit their GP and be frequent users of emergency services. Our work has also helped reduce non-emergency hospital admissions by 30 per cent. Bringing teams together is helping to reduce duplications and, in Newquay, to reduce on-going social care packages by 5.7 per cent. It’s saving money – around £400 per person.

Bringing people together is particularly important during the winter to ensure people have the right support in place before they’re discharged from hospital. We’ve teamed up with Volunteer Cornwall to support outpatients who don’t have any family or friends to care for them.

The new Welcome Home service involves volunteers meeting people at their home after they’ve been discharged from hospital to make sure they’re settled, have food, essential products and have friends, family or neighbours nearby who can support them. If they don’t, then the volunteer will either arrange for the voluntary sector or paid services to step in and support them.

All this has been achieved by giving people the freedom to think and work differently. We’ve connected with the people who are desperate to work beyond the confines of what is deemed to be the ‘proper’ way in the public sector – our ‘boat rockers’. We want them to flourish.

Trust and respect among organisations is critical to Living Well’s success. We’ve had to be quite radical in the way we share information among organisations to ensure what we do is safe and that patients benefit from this joined-up approach. In an ideal world we’d all be using a single information system. In reality, we can find ways of making a complicated system workable, but the absolute minimum requirement is that all agencies agree an information-sharing protocol and – crucially – a relationship of trust is developed. Honorary contracts with GP practices and providers are also useful tools.

Our challenge in embedding this approach can often seem overwhelming. There are the obvious financial issues and the balancing act of trying to transform and improve a system at a time of diminishing resources and that applies equally to the capacity of the voluntary sector, which has eroded during the past few years. Our challenge is also behavioural and cultural. Currently, we have a health and care system that can manufacture demand by offering people very limited opportunity to engage with their communities, but instead defaults and escalates to a clinical pathway. Within that system we have organisations that prioritise process over outcomes. We haven’t deliberately set out to do this but it is an unfortunate by-product of the way the health and care system has been organised, separated and driven by targets.

What’s worked for us is listening to people’s experiences of what works and, more importantly, what barriers they face every day. We’ve listened to them and then given them the tools and freedom they need to work differently, such as sharing information across all sectors to ensure people only have to tell their story once and that everyone involved with an individual’s care knows who’s supporting them, and why.

Our biggest challenge by far has been to embed the approach pioneered by our ‘boat rockers’; the people, the practitioners and the clinicians who are embracing Living Well as their own, developing and expanding it into areas of volunteering and community support; beginning to question their tasks and redesign their pathways to become more people focused and slowly transforming our system from separate silos to one that hangs together around a person and begins to shape what we can collectively offer around those individual goals.

We are still on our journey of making Living Well ‘business as usual’ but we will achieve it; we have a strong history in Cornwall of entrepreneurial spirit, of mavericks and radicals, of people willing to step beyond their boundaries to try something different and that will be our Living Well legacy.

We haven’t solved all our problems, but we know we’re on the right course.